Recommendations aimed at duplication of services by health care agencies

The General Accounting Office (GAO) has issued a report has issued its annual report on actions that various federal agencies can take to reduce, eliminate, or better handle fragmentation of services. The report makes recommendations for efforts that HHS, the FDA, and the VA can all make in order to better integrate, where possible and necessary, their efforts and services (GAO Report, GAO-18-371SP, April 26, 2018).

Background. Beginning in 2011, the GAO has issued an annual report aimed at eliminating or reducing fragmentation, overlap, or duplication of services provide by federal agencies. These reports were initially spurred by the recognition that the federal government faces an unsustainable fiscal future, driven in large part by health care spending. The most recent report offers suggestions aimed at efforts by the FDA, HHS, and VA.

Imported seafood oversight. More than 90 percent of the seafood consumed in the US comes from imported seafood and half of that comes from fish farming. Fish grown in these farms often experience high rates of bacterial infections for which farmers treat the fish with various antibiotic and antifungal drugs, some of which can cause cancer or allergic reactions. The FDA is responsible for ensuring the safety of all imported seafood but catfish, for which the Food Safety and Inspection Service has oversight. A 2017 report found that the two agencies had not fully coordinated on drug residue testing methods, for example in developing such methods for unapproved drugs. The report found that as a result, the two agencies were not leveraging each other’s knowledge and resources. The GAO recommended that the agencies coordinate in developing testing methods and stated that such improvement could lead to better coordination and communication, thereby better managing fragmentation of efforts.

Graduate medical education funding. The report recommended that HHS should coordinate with other agencies, including the VA, to improve the effectiveness and oversight of federal funding for physician graduate medical education. The government spent $14.5 billion on GME training in 2015 and that funding was spread across various agencies, with HHS funding the lion’s share. The GAO has warned that such fragmentation can lead to a lack of accountability of GME funds and that the agencies lack sufficient information to evaluate the performance of various federal GME programs. This leads to an inability to fully understand federal, specifically HHS, investment in GME funding, which leads to a failure to identify gaps between the programs’ results and actual workforce needs. The report recommended that HHS coordinate with other agencies to identify the information needed to evaluate these programs’ performance and opportunities to improve quality and consistency of the information collected.

VA human capital issues. The report also recommended that the VA improve its human resources control practices and its employee performance management processes. A 2016 report found that the VA’s Veterans Health Administration (VHA), which cares for approximately 6 million veterans, had limited human resources capacity. This, combined with insufficient human control practices, damaged the VHA’s ability to perform its mission. The report noted that the VHA has experienced high staff attrition rates, lacked clear lines of authority, and lacked effective coordination between its central and medical center HR offices. It further found that the VHA’s employee performance management system did not track basic HR practices, limiting the VHA’s ability to make meaningful distinctions between employee performances. The report recommended improvements to the HR capacity and the VHA has begun implementing the recommendations.

Premium tax credit payments. The report suggests that CMS and the IRS could save money by strengthening controls over the Premium Tax Credit (PTC) for health insurance. CMS oversees implementation of provisions ensuring that eligible individuals receive their PTC, while the IRS ensures compliance with health coverage and tax filing requirements. A July 2017 report found that CMS process regarding eligibility requirements for advance PTC payments and the accuracy of advance PTC calculations was deficient and made eight recommendations to improve its control activities. The same report found that the IRS control activities regarding determinations of eligibility, access to required health coverage, and notifications, were deficient and made three recommendations related to processing PTC information on tax returns.

IT investment portfolio management. A September 2016 GAO report recommended that the heads of twenty agencies, including HHS and the VA, direct their Chief Information Officers take steps to improve their software application inventories. This recommendation was intended to aid agencies in identifying duplicative or wasteful applications. To date, fifteen agencies have agreed with the recommendation. The VA has established a complete inventory. HHS has not provided an update on its efforts.

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